The lecture has been given on Nov. 2nd, 9th, & 23rd, 2010 by Dr. Gona.

1. BASIC AIRWAYBASIC AIRWAY
MANAGEMENTMANAGEMENT

2. Problems with airwaysProblems with airways
Snoring, indrawing of the supraclavicular,Snoring, indrawing of the supraclavicular,
suprasternal and intercostal spaces, usesuprasternal and intercostal spaces, use
of the accessory muscles or paradoxicalof the accessory muscles or paradoxical
respiratory movement (see-sawrespiratory movement (see-saw
respiration) suggest that manual airwayrespiration) suggest that manual airway
maneuvers (head tilt and jaw thrust)ormaneuvers (head tilt and jaw thrust)or
using oropharyngeal or nasopharyngealusing oropharyngeal or nasopharyngeal
airway methods are failing to maintain aairway methods are failing to maintain a
patent airway.patent airway.

3. Other problems with these techniques include:Other problems with these techniques include:
•• Inability to maintain a good seal between the patient’sInability to maintain a good seal between the patient’s
face and the mask, particularly in those without teeth;face and the mask, particularly in those without teeth;
•• Fatigue, when holding the mask for prolonged periods;Fatigue, when holding the mask for prolonged periods;
•• The risk of aspiration, due to the loss of upper airwayThe risk of aspiration, due to the loss of upper airway
reflexes;reflexes;
•• The anesthetist not being free to deal with any otherThe anesthetist not being free to deal with any other
problems that may arise.problems that may arise.
The laryngeal mask airway or tracheal intubation may beThe laryngeal mask airway or tracheal intubation may be
used to overcome these problemsused to overcome these problems

4. Laryngeal mask airway (LMA)Laryngeal mask airway (LMA)
Laryngeal masks are used in anesthesia and inLaryngeal masks are used in anesthesia and in
emergency medicine for airway management. Theyemergency medicine for airway management. They
consist of a tube with an inflatable cuff that is insertedconsist of a tube with an inflatable cuff that is inserted
into the pharynx. They cause less pain and coughinginto the pharynx. They cause less pain and coughing
than an endotracheal tube, and are much easier tothan an endotracheal tube, and are much easier to
insert.insert.
However, unlike an endotracheal tube, a laryngealHowever, unlike an endotracheal tube, a laryngeal
mask cannot protect the airway or lungs frommask cannot protect the airway or lungs from
aspiration of regurgitated material making themaspiration of regurgitated material making them
unsuitable for patients at risk for this complication, andunsuitable for patients at risk for this complication, and
deep (subglottic) suctioning cannot be performeddeep (subglottic) suctioning cannot be performed
through the mask.through the mask.

5. Laryngeal mask airway (LMA)Laryngeal mask airway (LMA)
The device is useful in situations where aThe device is useful in situations where a
patient is trapped in a sitting position,patient is trapped in a sitting position,
suspected of trauma to the cervical spinesuspected of trauma to the cervical spine
(where tilting the head to maintain an open(where tilting the head to maintain an open
airway is contraindicated), or whenairway is contraindicated), or when
intubation is unsuccessful. It is not insertedintubation is unsuccessful. It is not inserted
as far as an endotracheal tube (it sits tightlyas far as an endotracheal tube (it sits tightly
over the top of the larynx, and thus does notover the top of the larynx, and thus does not
need to be inserted into the trachea), andneed to be inserted into the trachea), and
supports both spontaneous and artificialsupports both spontaneous and artificial
ventilation. It is popular in day case surgery.ventilation. It is popular in day case surgery.

6. Guide to useGuide to use
The cuff is deflated and the mask lightly lubricated , aThe cuff is deflated and the mask lightly lubricated , a
head tilt is performed, the patient’s mouth opened fullyhead tilt is performed, the patient’s mouth opened fully
and the tip of the mask inserted along the hard palateand the tip of the mask inserted along the hard palate
with the open side facing but not touching the tongue.with the open side facing but not touching the tongue.
The mask is further inserted, using the index finger toThe mask is further inserted, using the index finger to
provide support for the tube. Eventually, resistance willprovide support for the tube. Eventually, resistance will
be felt at the point where the tip of the mask lies at thebe felt at the point where the tip of the mask lies at the
upper esophageal sphincterupper esophageal sphincter
The cuff is now fully inflated using an air-filled syringeThe cuff is now fully inflated using an air-filled syringe
attached to the valve at the end of the pilot tube, air entryattached to the valve at the end of the pilot tube, air entry
is confirmed by listening for air entry into the lungs with ais confirmed by listening for air entry into the lungs with a
stethoscope, or by presence of end tidal carbon dioxide.stethoscope, or by presence of end tidal carbon dioxide.
. • The laryngeal mask is secured either by a length of. • The laryngeal mask is secured either by a length of
bandage or adhesive strapping attached to thebandage or adhesive strapping attached to the
protruding tubeprotruding tube

9. Tracheal intubationTracheal intubation
This is the best method of providing and securing aThis is the best method of providing and securing a
clear airway in patients during anesthesia andclear airway in patients during anesthesia and
resuscitation, but success requires abolition of theresuscitation, but success requires abolition of the
laryngeal reflexes.laryngeal reflexes.
During anesthesia, this is usually achieved by theDuring anesthesia, this is usually achieved by the
administration of a muscle relaxant. Deep inhalationaladministration of a muscle relaxant. Deep inhalational
anesthesia or local anesthesia of the larynx can also beanesthesia or local anesthesia of the larynx can also be
used, but these are usually reserved for patients whereused, but these are usually reserved for patients where
difficulty with intubation is anticipated, for example in thedifficulty with intubation is anticipated, for example in the
presence of airway tumors or immobility of the cervicalpresence of airway tumors or immobility of the cervical
spine.spine.

10. Common indications for tracheal intubationCommon indications for tracheal intubation
1-To maintain patent airway1-To maintain patent airway
••Unconscious (GCS<8)Unconscious (GCS<8)
•• Where the position of the patient would make airway maintenance difficult, forWhere the position of the patient would make airway maintenance difficult, for
example the lateral or prone position.example the lateral or prone position.
••Where there is competition between surgeon and anesthetist for the airway (e.g.Where there is competition between surgeon and anesthetist for the airway (e.g.
operations on the head and neck).operations on the head and neck).
•• In those patients in whom the airway cannot be satisfactorily maintained by anyIn those patients in whom the airway cannot be satisfactorily maintained by any
other technique e.g. obese patient, beard patientother technique e.g. obese patient, beard patient
•• During cardiopulmonary resuscitationDuring cardiopulmonary resuscitation
2-To allow ventilation2-To allow ventilation
•• Where muscle relaxants are used to facilitate surgery (e.g. abdominal andWhere muscle relaxants are used to facilitate surgery (e.g. abdominal and
thoracic surgery), thereby necessitating the use of mechanical ventilation.thoracic surgery), thereby necessitating the use of mechanical ventilation.
•• Where controlled ventilation is utilized to improve surgical access (e.g.Where controlled ventilation is utilized to improve surgical access (e.g.
neurosurgeryneurosurgery
••Patient with respiratory failurePatient with respiratory failure
•• To minimize the dose of volatile agent and /or allow large doses of narcoticsTo minimize the dose of volatile agent and /or allow large doses of narcotics
3-To prevent aspiration3-To prevent aspiration
•• In patients with a full stomach, (emergency operation, Caesarian section, uremic,In patients with a full stomach, (emergency operation, Caesarian section, uremic,
diabetic gastroparesis, obese) to protect against aspiration.diabetic gastroparesis, obese) to protect against aspiration.
4-Allow bronchial suction4-Allow bronchial suction

11. Observation of the patient’s anatomyObservation of the patient’s anatomy
Look for:Look for:
•• Limitation of mouth opening;Limitation of mouth opening;
•• A receding mandible;A receding mandible;
•• Position, number and health of teeth;Position, number and health of teeth;
•• Size of the tongue;Size of the tongue;
•• Soft tissue swelling at the front of the neck;Soft tissue swelling at the front of the neck;
•• Deviation of the larynx or trachea;Deviation of the larynx or trachea;
•• Limitations in flexion and extension of the cervical spine.Limitations in flexion and extension of the cervical spine.
Finding any of these suggests that intubation may be moreFinding any of these suggests that intubation may be more
difficult. However, it must be remembered that all ofdifficult. However, it must be remembered that all of
these are subjective.these are subjective.

12. Simple bedside testsSimple bedside tests
•• Mallampati criteriaMallampati criteria The patient, sitting upright, is asked to openThe patient, sitting upright, is asked to open
his mouth and maximally protrude his tongue. The view of thehis mouth and maximally protrude his tongue. The view of the
pharyngeal structures is noted and graded I–IVpharyngeal structures is noted and graded I–IV
Grades III and IV suggest difficult intubation.Grades III and IV suggest difficult intubation.
•• Thyromental distanceThyromental distance With the head fully extended on theWith the head fully extended on the
neck, the distance between the bony point of the chin and theneck, the distance between the bony point of the chin and the
prominence of the thyroid cartilage is measured. A distance ofprominence of the thyroid cartilage is measured. A distance of
less than 7 cm suggests difficult intubation.less than 7 cm suggests difficult intubation.
None of these tests, alone or in combination, predicts allNone of these tests, alone or in combination, predicts all
difficult intubations. A Mallampati grade III or IV with adifficult intubations. A Mallampati grade III or IV with a
thyromental distance of <7cm predict 80% of difficultthyromental distance of <7cm predict 80% of difficult
intubations.intubations.
If problems are anticipated, anesthesia should be plannedIf problems are anticipated, anesthesia should be planned
accordingly.accordingly.
If intubation proves to be difficult, it must be recorded in aIf intubation proves to be difficult, it must be recorded in a
prominent place in the patient’s notes and the patient informed.prominent place in the patient’s notes and the patient informed.

15. Routes for IntubationRoutes for Intubation
OrotrachealOrotracheal
NasotrachealNasotracheal
TracheotomyTracheotomy

16. Oral IntubationOral Intubation

17. Equipment for tracheal intubationEquipment for tracheal intubation
The equipment used will be determined by theThe equipment used will be determined by the
circumstances and by the preferences of the individualcircumstances and by the preferences of the individual
anesthetist.anesthetist.
The following is a list of the basic needs forThe following is a list of the basic needs for adult oraladult oral
intubation.intubation.
•• LaryngoscopeLaryngoscope: with a curved (Macintosh) blade and: with a curved (Macintosh) blade and
functioning light.functioning light.
LaryngoscopeLaryngoscope
It’s a rigid instrument used to examine the larynx and toIt’s a rigid instrument used to examine the larynx and to
facilitate intubation of the trachea.facilitate intubation of the trachea.
The laryngoscope is held in your non dominant handThe laryngoscope is held in your non dominant hand
carefully introduce the blade into the right side of the mouthcarefully introduce the blade into the right side of the mouth
(Never press against the teeth), the tongue is then swept to(Never press against the teeth), the tongue is then swept to
the left and up into the flour of pharynx by the bladethe left and up into the flour of pharynx by the blade’’ss
flange and advancing the blade toward the glottic openingflange and advancing the blade toward the glottic opening
then pass the tube into the right side of the mouth andthen pass the tube into the right side of the mouth and
through the vocal cords (using the dominant hand)through the vocal cords (using the dominant hand)

18. •• Tracheal tubes (cuffed)Tracheal tubes (cuffed): in a variety of sizes.: in a variety of sizes.
The internal diameter is expressed in millimetersThe internal diameter is expressed in millimeters
and the length in centimeters. They may beand the length in centimeters. They may be
lightly lubricated.lightly lubricated.
•• For males: 8.0–9.0mm internal diameter, 22–For males: 8.0–9.0mm internal diameter, 22–
24cm length24cm length
•• For females: 7.5–8.5mm internal diameter, 20–For females: 7.5–8.5mm internal diameter, 20–
22cm length.22cm length.
•• SyringeSyringe: to inflate the cuff once the tube is in: to inflate the cuff once the tube is in
place.place.
•• Catheter mountCatheter mount: or ‘elbow’ to connect the tube: or ‘elbow’ to connect the tube
to the anesthetic system or ventilator tubing.to the anesthetic system or ventilator tubing.
•• SuctionSuction: switched on and immediately to hand: switched on and immediately to hand
in case the patient vomits or regurgitates.in case the patient vomits or regurgitates.

19. •• StethoscopeStethoscope: to check correct placement: to check correct placement
of the tube by listening for breathe soundsof the tube by listening for breathe sounds
during ventilationduring ventilation
•• ExtrasExtras: a semi-rigid introducer to help: a semi-rigid introducer to help
mould the tube to a particular shape;mould the tube to a particular shape;
Magill’s forceps, designed to reach intoMagill’s forceps, designed to reach into
the pharynx to remove debris or direct thethe pharynx to remove debris or direct the
tip of a tube; bandage or tape to securetip of a tube; bandage or tape to secure
the tube.the tube.

20. Visualization of Vocal CordsVisualization of Vocal Cords

21. Tracheal tubesTracheal tubes
Mostly manufactured from plastic (PVC), and for single useMostly manufactured from plastic (PVC), and for single use
to eliminate cross-infectionto eliminate cross-infection
They are available in 0.5mm diameter intervals, and longThey are available in 0.5mm diameter intervals, and long
enough to be used orally or nasally. A standard 15mmenough to be used orally or nasally. A standard 15mm
connector is provided to allow connection to theconnector is provided to allow connection to the
breathing system.breathing system.
In adult anesthesia, a tracheal tube with an inflatable cuffIn adult anesthesia, a tracheal tube with an inflatable cuff
is used to prevent leakage of anesthetic gases back pastis used to prevent leakage of anesthetic gases back past
the tube when positive pressure ventilation is used. Thisthe tube when positive pressure ventilation is used. This
also helps prevent aspiration of any foreign material intoalso helps prevent aspiration of any foreign material into
the lungs.the lungs.
The cuff is inflated by injecting air via a pilot tube, at theThe cuff is inflated by injecting air via a pilot tube, at the
distal end of which is a one-way valve to preventdistal end of which is a one-way valve to prevent
deflation and a small ‘balloon’ to indicate when the cuff isdeflation and a small ‘balloon’ to indicate when the cuff is
inflated.inflated.

22. A wide variety of specialized tubes have beenA wide variety of specialized tubes have been
developeddeveloped
•• Reinforced tubesReinforced tubes are used to prevent kinking and subsequentare used to prevent kinking and subsequent
obstruction as a result of the positioning of the patient’s headobstruction as a result of the positioning of the patient’s head
•• Preformed tubesPreformed tubes are used during surgery on the head andare used during surgery on the head and
neck, and are designed to take the connections away from theneck, and are designed to take the connections away from the
surgical fieldsurgical field
•• Double lumen tubesDouble lumen tubes are effectively two tubes welded togetherare effectively two tubes welded together
side-by-side, with one tube extending distally beyond the other.side-by-side, with one tube extending distally beyond the other.
They are used during thoracic surgery, and allow one lung toThey are used during thoracic surgery, and allow one lung to
be deflated whilst ventilation is maintained via the bronchialbe deflated whilst ventilation is maintained via the bronchial
portion in the opposite lungportion in the opposite lung
•• Uncuffed tubesUncuffed tubes are used in children up to approximately 10are used in children up to approximately 10
years of age as the narrowing in the subglottic region providesyears of age as the narrowing in the subglottic region provides
a natural seala natural seal

23. Endotracheal TubeEndotracheal Tube

26. The technique of oral intubationThe technique of oral intubation
PreoxygenationPreoxygenation
All patients who are to be intubated are asked toAll patients who are to be intubated are asked to
breathe 100% oxygen via a close-fittingbreathe 100% oxygen via a close-fitting
facemask for 2–3 mins (‘preoxygenation’). Thisfacemask for 2–3 mins (‘preoxygenation’). This
provides a reservoir of oxygen in the patient’sprovides a reservoir of oxygen in the patient’s
lungs, reducing the risk of hypoxia if difficulty islungs, reducing the risk of hypoxia if difficulty is
encountered with intubation. Once this has beenencountered with intubation. Once this has been
accomplished, the appropriate drugs will beaccomplished, the appropriate drugs will be
administered to render the patient unconsciousadministered to render the patient unconscious
and abolish laryngeal reflexes.and abolish laryngeal reflexes.

27. PositioningPositioning
The patient’s head is placed on a smallThe patient’s head is placed on a small
pillow with the neck flexed and the headpillow with the neck flexed and the head
extended at the atlanto-occipital joint, theextended at the atlanto-occipital joint, the
‘sniffing the morning air’ position. The‘sniffing the morning air’ position. The
patient’s mouth is fully opened using thepatient’s mouth is fully opened using the
index finger and thumb of theindex finger and thumb of the rightright hand inhand in
a scissor action.a scissor action.

28. Patient PositioningPatient Positioning
GoalGoal
Align 3 planes ofAlign 3 planes of
view, so vocalview, so vocal
cords are mostcords are most
visiblevisible
T - tracheaT - trachea
P - PharynxP - Pharynx
O - OropharynxO - Oropharynx

29. Patient PositioningPatient Positioning

31. LaryngoscopeLaryngoscope
The laryngoscope is held in the leftThe laryngoscope is held in the left hand andhand and
the blade introduced into the mouth along thethe blade introduced into the mouth along the
right side of the tongue, displacing it to the left.right side of the tongue, displacing it to the left.
The blade is advanced until the tip lies in theThe blade is advanced until the tip lies in the
gap between the base of the tongue and thegap between the base of the tongue and the
epiglottis, the vallecula. Force is then applied inepiglottis, the vallecula. Force is then applied in
the direction in which the handle of thethe direction in which the handle of the
laryngoscope is pointinglaryngoscope is pointing.. The effort comesThe effort comes
from the upper arm not the wrist, to lift thefrom the upper arm not the wrist, to lift the
tongue and epiglottis to expose the larynx,tongue and epiglottis to expose the larynx,
seen as a triangular opening with the apexseen as a triangular opening with the apex
interiorly and the whitish coloured true cordsinteriorly and the whitish coloured true cords
laterallylaterally

32. LaryngoscopeLaryngoscope

33. Curved bladeCurved blade

34. Straight bladeStraight blade

35. IntubationIntubation
The tracheal tube is introduced into the rightThe tracheal tube is introduced into the right
side of the mouth, advanced and seen to passside of the mouth, advanced and seen to pass
through the cordsthrough the cords until the cuff lies just belowuntil the cuff lies just below
the cords. The tube is then held firmly and thethe cords. The tube is then held firmly and the
laryngoscope is carefully removed, and the cufflaryngoscope is carefully removed, and the cuff
is inflated sufficiently to prevent any leak duringis inflated sufficiently to prevent any leak during
ventilation. Finally the position of the tube isventilation. Finally the position of the tube is
confirmed and secured in place.confirmed and secured in place.

36. For nasotracheal intubation a well-lubricatedFor nasotracheal intubation a well-lubricated
tube is introduced, usually via the right nostriltube is introduced, usually via the right nostril
along the floor of the nose with the bevelalong the floor of the nose with the bevel
pointing medially to avoid damage to thepointing medially to avoid damage to the
turbinates. It is advanced into the oropharynx,turbinates. It is advanced into the oropharynx,
where it is usually visualized using awhere it is usually visualized using a
laryngoscope in the manner described above.laryngoscope in the manner described above.
It can then either be advanced directly into theIt can then either be advanced directly into the
larynx by pushing on the proximal end, or thelarynx by pushing on the proximal end, or the
tip picked up with Magill’s forceps (which aretip picked up with Magill’s forceps (which are
designed not to impair the view of the larynx)designed not to impair the view of the larynx)
and directed into the larynx. The procedureand directed into the larynx. The procedure
then continues as for oral intubation.then continues as for oral intubation.

37. Nasal IntubationNasal Intubation

38. Confirming the position of the tracheal tubeConfirming the position of the tracheal tube
This can be achieved using a number ofThis can be achieved using a number of
techniques:techniques:
•• Measuring the carbon dioxide in expired gasMeasuring the carbon dioxide in expired gas
(capnography)(capnography)::
Less than 0.2% indicates esophageal intubation.Less than 0.2% indicates esophageal intubation.
•• Direct visualizationDirect visualization: of the tracheal tube passing: of the tracheal tube passing
between the vocal cords.between the vocal cords.
•• FoggingFogging: on clear plastic tube connectors during: on clear plastic tube connectors during
expiration.expiration.

39. Less reliable signs areLess reliable signs are
•• Diminished breath sounds on auscultation;Diminished breath sounds on auscultation;
•• decreased chest movement on ventilation;decreased chest movement on ventilation;
•• gurgling sounds over the epigastrium andgurgling sounds over the epigastrium and
‘Burping’ sounds as gas escapes;‘Burping’ sounds as gas escapes;
•• A decrease in oxygen saturation detected byA decrease in oxygen saturation detected by
pulse oximetry. This occurs late, particularly ifpulse oximetry. This occurs late, particularly if
the patient has been preoxygenated.the patient has been preoxygenated.

40. Complications of tracheal intubationComplications of tracheal intubation
The following complications are the more common ones, notThe following complications are the more common ones, not
an attempt to cover all occurrences.an attempt to cover all occurrences.
HypoxiaHypoxia
Due to:Due to:
•• UnrecognizedUnrecognized eesophageal intubationsophageal intubation
If there is any doubt about the position of the tube it shouldIf there is any doubt about the position of the tube it should
be removed and the patient ventilated via a facemask.be removed and the patient ventilated via a facemask.
•• Failed intubation and inability to ventilate the patientFailed intubation and inability to ventilate the patient
This is usually a result of abnormal anatomy or airwayThis is usually a result of abnormal anatomy or airway
pathology. Many cases are predictable at the preoperativepathology. Many cases are predictable at the preoperative
assessmentassessment
•• Failed ventilation after intubationFailed ventilation after intubation
Possible causes include the tube becoming kinked,Possible causes include the tube becoming kinked,
disconnected, or inserted too far and passing into one maindisconnected, or inserted too far and passing into one main
bronchus; severe bronchospasm and tension pneumothorax.bronchus; severe bronchospasm and tension pneumothorax.

41. •• AspirationAspiration
Regurgitated gastric contents can cause blockageRegurgitated gastric contents can cause blockage
of the airways directly, or secondary to laryngealof the airways directly, or secondary to laryngeal
spasm and bronchospasm.spasm and bronchospasm.
Cricoid pressure can be used to reduce the risk ofCricoid pressure can be used to reduce the risk of
regurgitation prior to intubationregurgitation prior to intubation
TraumaTrauma
•• DirectDirect During laryngoscope and insertion of theDuring laryngoscope and insertion of the
tube, damage to lips, teeth, tongue, pharynx, larynx,tube, damage to lips, teeth, tongue, pharynx, larynx,
trachea, and nose and nasopharynx during nasaltrachea, and nose and nasopharynx during nasal
intubation; causing soft tissue swelling or bleeding.intubation; causing soft tissue swelling or bleeding.
•• IndirectIndirect To the recurrent laryngeal nerves, and theTo the recurrent laryngeal nerves, and the
cervical spine and cord, particularly where there iscervical spine and cord, particularly where there is
pre-existing degenerative disease or trauma.pre-existing degenerative disease or trauma.

42. Reflex activityReflex activity
•• Hypertension and arrhythmiasHypertension and arrhythmias Occurs in response toOccurs in response to
laryngoscope and intubation. May jeopardize patients withlaryngoscope and intubation. May jeopardize patients with
coronary artery diseasecoronary artery disease
In patients at risk, specific action is taken to attenuate theIn patients at risk, specific action is taken to attenuate the
response; for example pretreatment with beta blockers orresponse; for example pretreatment with beta blockers or
potent analgesics (fentanyl, remifentanil).potent analgesics (fentanyl, remifentanil).
•• VomitingVomiting This may be stimulated when laryngoscopy isThis may be stimulated when laryngoscopy is
attempted in patients who are inadequately anaesthetized. It isattempted in patients who are inadequately anaesthetized. It is
more frequent when there is material in the stomach; formore frequent when there is material in the stomach; for
example in emergencies when the patient is not starved, inexample in emergencies when the patient is not starved, in
patients with intestinal obstruction, or when gastric emptying ispatients with intestinal obstruction, or when gastric emptying is
delayed, as after opiate analgesics or following trauma.delayed, as after opiate analgesics or following trauma.
•• Laryngeal spasmLaryngeal spasm Reflex adduction of the vocal cords as aReflex adduction of the vocal cords as a
result of stimulation of the epiglottis or larynxresult of stimulation of the epiglottis or larynx